Renegotiating the 'Contract for Safety' in the ER

Renegotiating the 'Contract for Safety' in the ER

"Will the patient contract for safety?" a clinician or insurance representative at the other end of the line wants to know. "I don't know," I answer. Often I will add, "And I don't care." I then explain why I believe that an emergency room (ER) "contract for safety" is clinically unsound and can, for some patients, lead to disaster.

Interpreting a 'Cry for Help'

"I want out," a despondent "Julia" told her primary care physician in his office. Along with hypertension, fluid retention, glaucoma and asthma, this 36-year-old woman had been treated for depression during the last year. Concerned about her safety after hearing this apparent cry from the depths, the doctor drove her to the ER. "I want out," Julia told the triage nurse during the initial medical evaluation.

When I entered her room, Julia was lying quietly on a gurney. Her mother and father sat in chairs, looking grave. I needed to talk to Julia alone and suggested to the parents that they go to the waiting room.

Julia was not married, did not have children and lived with her parents. She worked as a nurse-technician at a nearby hospital. Julia had been feeling well until a year before, when her 89-year-old grandfather died. After his death, Julia was overwhelmed with grief and became depressed. Her primary care physician started her on fluoxetine (Prozac), which was titrated to 40 mg. The drug worked at first by calming her down. Julia's doctor told her that she had a "disease." She did not see a psychotherapist.

One month before coming to the ER, Julia's 89-year-old grandmother died. With this second death of a close family member in less than a year, Julia's depression became more severe. She began to lose sense of who she was. Her antidepressant was increased to 60 mg without apparent effect. In some way Julia could not specify, she began to feel "unsafe."

Julia continued working but found it hard to concentrate. She felt under constant stress, had interrupted sleep and was tired during the day. She "ate everything in sight," gained weight, had little interest in doing many of the things she normally did and associated only with family members and co-workers.

Fifteen years earlier, Julia had been depressed and saw a psychotherapist for six months. She could not recall what was going on in her life at that time that might have predisposed her to depression. Julia did not drink alcohol or use illicit drugs. She was taking medication for asthma and hypertension; both were well controlled.